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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Retail Fuel / 13 17 : 5P0 O7 o q <br /> OWNER I OPERATOR VandePol Petoleum CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> Van De Pol Ent Inc / Pacific Pride <br /> SITE ADD 91 N Beckman Rd Lodi 95240 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SAME <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT APN # LAND USE APPLICATION # <br /> ( 209 ) 944- 9115 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 209 ) 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Carrie Miller CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # EXT. <br /> Elite IV Contractors 20 %461 -6337 <br /> HOME or MAILING ADDRESS FAX # <br /> 2535 Wigwam Dr ( 209 ) 461 -6342 <br /> CITY Stockton STATE CA Zip 95205 <br /> BILLING ACKNOWLEDGEMENT: 1 , the undersigned property or business owner, operator or authorized agent of same , <br /> acknowledge that all Site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or <br /> activity will be billed to me or my business as identified on this form . <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws . <br /> APPLICANT'S SIGNATURE : C4404 � ?d4&404. DATE : 10/ 10/2023 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT EJ Office Manager <br /> If APPLICANT is not the BILLING PARTY. proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it is prC�jClQa jQ me or <br /> my representative . / �, ` � A A ,. <br /> TYPE OF SERVICE REQUESTED : S /2P / / [ ) J 7 / VE D <br /> COMMENTS : <br /> > ` UCT 12 202 <br /> I SAN JCAQUI <br /> HEgLTH p &TMS COUA rY <br /> T <br /> ACCEPTED BY : S' , lw) + EMPLOYEE #: DATE: / Q 77 2 <br /> ASSIGNED TO : EMPLOYEE #: DATE: % CJ// <br /> Date Service Comple d ( If a(eady completed ) : SERVICE CODE: Cas' _ PIE: .;7 <br /> Fee Amount: ` V Amount Paid (o �� Payment Date <br /> Payment Type r Invoice # Check # 170 1 S3 Received By: <br /> EHD 48-02-025 SR FORM ( Golden Rod) <br /> 07/17/08 <br />